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History of Posterior Continuous Curvilinear Capsulorhexis and Optic

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History of Posterior Continuous Curvilinear Capsulorhexis and Optic HISTORY OF POSTERIOR CONTINUOUS CURVILINEAR BY HOWARD V. GIMBEL, MD, MPH, FRCSC CAPSULORHEXIS AND OPTIC CAPTURE This useful technique is not just for pediatric surgery. econdary cataracts after pedi- I first used this technique in 1987 children in a publication coauthored atric cataract surgery have long to remove a dense posterior capsular with DeBroff in 1994.4 been recognized as an expected plaque and in 1988 to convert a PC In my early experience, the PCCC complication when the posterior tear to a PCCC.2 was done after the IOL was in the bag capsule is left intact. Planned Optic capture in the anterior con- so that, in the event of an unsuccess- Santerior vitrectomy after posterior tinuous curvilinear capsulorhexis was ful PCCC, the IOL would already be capsulectomy or capsulotomy is now described by Neuhann and Neuhann safely in the bag. To keep the vitreous performed routinely with cataract and in a film, “The Rhexis-Fixated Lens,” from coming through the PCCC as it IOL surgery in children. This is because, in 1991.3 With the experience I was being fashioned, a highly cohesive even with the posterior capsule open gained using that technique in adult OVD was placed through the first and the IOL in the bag, lens epithelial cataract surgery, it seemed obvious small tear in the PC. Then more OVD cell migration can proceed through that, after performing a PCCC, the was added as the tear was completed the posterior continuous curvilinear same capture technique could be with forceps. Optic capture was then capsulorhexis (PCCC), behind the IOL, used with the haptics left in the bag performed slowly, one edge at a time, and across the visual axis, making it and the optic captured by the PCCC. so that some of the cohesive OVD evident that the anterior vitreous must I expected that this would seal the behind the IOL could escape, and the be removed to eliminate this scaffold opening and prevent the aforemen- vitreous would not be pushed out for cell migration. tioned complication of cell migration through the PCCC. After the development of anterior through the PCCC and across the A PCCC of 4.0 mm or 4.5 mm continuous curvilinear capsulorhexis,1 intact vitreous face in pediatric cata- resulted in a very tight seal after it became obvious that tears in the ract surgery. optic capture. During irrigation and posterior capsule should, if possible, aspiration of the OVD from the be converted to a PCCC. In addition, EARLY EXPERIENCE anterior chamber, I also used slight opening the posterior capsule (PC) I first combined PCCC with optic pressure on the IOL to prevent with the PCCC technique in the pres- capture in children’s eyes undergo- the vitreous and the OVD behind ence of a dense plaque leaves a strong ing cataract surgery in April 1993. I the lens from pushing the optic capsular bag in which to place an described the technique and my early out of capture when the chamber implant. experience using it in eight eyes of became more shallow as the OVD JANUARY 2019 | CATARACT & REFRACTIVE SURGERY TODAY 43 s MASTERING THE POSTERIOR CAPSULE was aspirated. Postoperatively, the chamber. The lower OVD was trapped behind the IOL incidence of pediatric “THE PCCC TECHNIQUE WITH OPTIC optic and caused no IOP spike as it glaucoma in pseudo- was gradually metabolized. phakic eyes compared CAPTURE HAS BECOME WIDELY USED … IN At that time, we were using the with aphakic eyes may be PEDIATRIC CATARACT SURGERY, one-piece PMMA 811B CeeOn lens related to the compartmen- (Pharmacia; no longer available) with talization that an optic-captured PERHAPS BECAUSE … THE TECHNIQUE a 6.0-mm optic and narrow, thin, IOL provides, as the captured optic optic-haptic junctions that were at provides a more definitive, sealed CONVEYS OTHER ADVANTAGES right angles to the optic. This resulted separation of the two compartments. in a tight seal of the capsule to the The double optic capture tech- IN ADDITION TO PREVENTION lens around these junctions. Other nique proposed by DeBroff and surgeons using one-piece PMMA IOLs Nihalani has yet another advantage.8 OF SECONDARY with broad optic-haptic junctions With the haptics in the sulcus, the found that, in a significant number IOL–capsular bag complex will be CATARACT.” of cases, there was still cell migra- more stable in the event of progres- tion across an intact vitreous face.5,6 sive zonular weakness. disease, and/ Vasavada et al more recently reported We know that the haptics of one- or multifocal that the posterior optic capture tech- piece acrylic IOLs cannot be placed in IOL implantation. nique, used with foldable three-piece the sulcus, so both the DeBroff vitrec- Complications of acrylic IOLs that also have narrow tomy-plus-double-optic capture tech- Nd:YAG laser posterior optic-haptic junctions, successfully nique for children and the hyaloid- capsulotomies are rare, prevented secondary cataract.7 sparing double capture technique of but they do happen. They It appears that a narrow optic- Arbisser (unpublished) are limited to can include floaters, laser pits haptic junction is necessary only use with IOLs with thin haptics. on the IOL, incomplete open- with PMMA IOLs. Using the same ings that leave small apertures causing technique with one-piece foldable ROUTINE USE glare, retinal detachment, macular hydrophobic acrylic IOLs, we have In adults, the risk of cell migration edema, macular holes, uveitis, and seen no cell migration across the behind a PCCC-captured IOL may glaucoma.10 vitreous face to cause second- not be as great as in pediatric cases. Lisa Brothers Arbisser, MD, the ary cataract. The IOL material and However, the established incidence of guest editor of this cover focus, has right-angled edges of these lenses secondary opacification of the pos- taken up the torch in promoting the and haptics possibly contribute to terior capsule due to lens epithelial routine use of PCCC plus optic cap- the tight barrier at their optic-haptic cell migration and/or fibrin forma- ture in adult cataract surgery to avoid junctions, preventing cells from get- tion gives merit to the routine use of the necessity for and risks of Nd:YAG ting behind the IOL. PCCC with optic capture to eliminate laser posterior capsulotomy and to visual axis opacification in adults as convey the technique’s other advan- ADVANTAGES AND LIMITATIONS well as in children. tages. Her technique, unlike DeBroff’s The PCCC technique with optic In 2008, Menapace published a in pediatric cataract, does not include capture has become quite widely report of his excellent study of a vitrectomy. used, with or without anterior vitrec- large series of adult cataract surger- tomy, in pediatric cataract surgery, ies using PCCC and what he termed MANAGING COMPLICATIONS perhaps because in this setting the optic buttonholing without vitrectomy.9 Neuhann’s rhexis fixation and our technique conveys other advantages He recommended that use of this PCCC with optic capture technique in addition to prevention of second- technique for the prevention of sec- have been used in many ways to ary cataract. First, it ensures a stable, ondary cataract in pediatric cataract manage a number of intraoperative centered IOL that is fixed to the surgery should be extended to adults and postoperative complications. In capsule. Second, whether used with to avoid the known risks of Nd:YAG 2004, we published six variations of or without anterior vitrectomy, it has laser capsulotomy. He recommended optic capture, including reverse optic the advantage of maintaining the two that buttonholing be done routinely capture (ROC).11 Masket and Fram separate compartments of the eye. in adult surgery, at least in eyes with described the use of the ROC tech- Without optic capture, vitreous ele- pseudoexfoliation syndrome, high nique for reducing dysphotopsia.12 ments can have access to the anterior axial myopia, peripheral retinal We described its use to rotationally 44 CATARACT & REFRACTIVE SURGERY TODAY JANUARY 2019 MASTERING THE POSTERIOR CAPSULE s s WATCH IT NOW stabilize a one-piece acrylic toric IOL in a large cap- sular bag.13 Jones and colleagues described their technique of ROC for implanting a one-piece VIDEO 1 VIDEO 2 acrylic IOL after PC BIT.LY/0119GIMBEL1 BIT.LY/0119GIMBEL2 tear and anterior vitrec- tomy.14 We have recently 6. Vasavada A, Trivedi RH, Singh R. Necessity of vitrectomy when optic described an alternative tech- CONCLUSION capture is performed in children older than 5 years. J Cataract Refract Surg. nique of haptic tuck for ROC in Neuhann’s rhexis fixation and our 2001;27:1181-1193. 15 7. Vasavada A, Vasavada V, Shah S, et al. Postoperative outcomes of intraocular this situation. PCCC with optic capture techniques lens optic capture in pediatric cataract surgery. J Cataract Refract Surg. 2017;43:1177-1183. Another variation, membrane optic have prompted the application of the 8. DeBroff BM, Nihalani BR. Double optic capture with capsular bag fusion: a new technique for pediatric intraocular lens implantation. Techniques in capture (MOC), is a technique that optic capture concept in a number Ophthalmology. 2008;6(2):31-34. may be used to manage late compli- of other ways, such as ROC with an 9. Menapace R. Posterior capsulorhexis combined with optic buttonholing: an alternative to standard in-the-bag implantation of sharp-edged intraocular cations such as unstable or dislocated intact or compromised capsular bag, lenses? A critical analysis of 1000 consecutive cases. Graefes Arch Clin Exp Ophthalmol. 2008;246(6):787-801. IOLs. It also has applications in sec- haptic tuck for ROC, and MOC. Optic 10. Apple DJ, Solomon KD, Tetz MR, et al. Posterior capsule opacification.
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